Indications for Noninvasive Ventilation: When and For Whom?

Howard B. Panitch, M.D.Division of Pulmonary Medicine

Children’s Hospital of Philadelpia

Philadelphia, PA

Indications for Noninvasive Ventilation (NIV)

• Acute respiratory failure– Avoid intubation– Avoid extubation failure

• Chronic respiratory failure– Progression of chronic disease– Acute exacerbation of chronic disease

• Palliation

Goals of Noninvasive Ventilation in Acute Respiratory Failure

• Improve alveolar ventilation• Improve oxygenation• Unload respiratory muscles• Maintain upper airway patency

Noninvasive vs. Invasive Ventilation

Advantages• Avoid tracheal/laryngeal

injury• sedation• risk of ventilator-

associated pneumonia• tolerance of enteral

feedings• Preserve airway

clearance mechanisms

Disadvantages• Skin injury• Abdominal distension• Inadequate for more

severe disease• Delay in controlling a

failing/unstable patient

Some Indications for NIV in Acute Respiratory Failure

• Neonatal RDS• Bronchiolitis• Asthma• Pneumonia• Pediatric ARDS

– (mild to moderate)

Rationale for NIV in Acute Respiratory Failure

CPAP• Recruitment of

collapsed areas• Stabilize upper airway• Central airway patency• Improve P-V

relationships

NPPV• Unload respiratory

muscles• Enhance ventilation• Alveolar recruitment

Mechanisms of NIV in Pediatric ARDS

Essouri S et al. Pediatr Crit Care Med 16:S102; 2015

PSV

CPAP

CPAP

Contraindications for NIV in Acute Respiratory Failure

• Exhaustion– Abdominal muscle use with thoraco-

abdominal paradox• SpO2/FiO2 <150• PaCO2 >55• pH < 7.30

Calderini E et al. Curr Opin Anaesthes 23:368; 2010

Use of NIV for Acute Respiratory Failure (2006-

2012)

Indication and Failure Rate Mode of Support by Age

Wolfler A et al. Pediatr Crit Care Med 16:418; 2015

N = 585 (15%)

NIV for Status Asthmaticus

Basnet S et al. Pediatr Crit Care Med 13: 393; 2012

HRFiO2

RRAsthmaScore

Long-Term NIV for Chronic Respiratory Failure

Castro-Codesal ML et al. PLoS ONE 13:e0192111; 2018

Respiratory Failure

Lung Failure “Pump” Failure

Gas exchange FailureHypoxemia

Ventilatory FailureHypercapnea

Central Depression

MechanicalDefect

FatigueFrom Roussos C and Macklem PT. N Engl J Med 307:786; 1982

Advantages of NIV for Chronic Respiratory Failure

• Decreased risk of nosocomial pneumonia

• Management outside of an ICU• Less sedation• Improved tolerance of enteral

feedings• Ambulation/improved mobility

Chronic Respiratory Failure

Lung Failure “Pump” Failure

Obstructive Diseases• COPD• Bronchiectasis

• Cystic fibrosis• BPD

Restrictive Diseases• Neuromuscular Disease• Chest wall deformities• Spinal cord injuries• Diaphragm paralysis• Hypertonic cerebral palsy

Control of breathing disorders• CCHS

Pulmonary Home Ventilation Program

0

20

40

60

80

100

120

140

160

180

Airway CHD CLD COB Neuro NMD OSA RLD

NIVTrach

Goals of Noninvasive Ventilation

• Prolong survival• Normalize gas exchange• Reverse/correct sleep-disordered

breathing and architecture• Prevent / reverse cor pulmonale• Improve daytime function• Sustain/promote growth and

development

Goals of Mechanical Ventilation in Progressive

Diseases• Palliate dyspnea• Support during acute illnesses• Reverse hypoventilation• Improve sleep quality• Facilitate home care/reduce

hospitalizations• Remodel thorax, ?promote lung growth

Chest Wall Compliance in Children with NMD

Cw ml/cm H2O /kg

Papastamelos C et al. Am J Respir Crit Care Med 154:1045; 1996

Age, mos

10

00 24 48

8

2

6

4

4 yrs after NIPPV

Simonds AK. In Non-Invasive Respiratory

Support, Simonds AK, ed. pp 181-2;

2001

Lung Insufflation and Chest Wall Shape

7 mo 3 yr, 6 mo

Bach Jr and Bianchi C. Am J Phys Med Rehabil 82:815; 2003

Types of Sleep Problems

Hull J et al. Thorax 67:i1; 2012

Mechanical Ventilatory SupportWhen to Begin?

• Evaluate when daytime PaCO2 > 45 torr1,2

• Acute respiratory illness and failure to wean

• Abnormal polysomnography

• ?Preventative treatment?• Preservation / promotion of lung growth?

1Rutgers M et al. Neuromuscul Disord 6:431; 19962Finder J et al. Am J Respir Crit Care Med 170:456; 2004

Sritippapayawan S et al. J Pediatr 142:481; 2003

Before 1987 1987-1989 1990-1992 1993-1995 1996-1998 1999-20010

2

4

6

8

10

12

14

PSG

Elective HMV Non-elective HMV

# of Patients

Introduction of Chronic Ventilation

Predictors of SDBIVC, PaCO2

Mellies U et al. Neuromuscul Disord 13:123; 2003

Sens 97%Spec 87%

Sens 96%Spec 88% Sens 92%

Spec 72%

RCT for Those with Nocturnal Hypoventilation

• daytime PaCO2(n = 5)

• Symptomatic relief (n = 2)

• FTT, acute pneumonia (n = 1)

• TcCO2, in PFTs (n = 1)

1

2

3

4

5

6

7

8

9

10

PatientNo Months from entry into study (0 – 24)

Baseline0%

6 months50%

12 months70%

24 months90%

18 months70%

no NIV on NIV

Reason for Initiation of NIV

Ward S et al. Thorax 60:1019; 2005

How Should We Target Ventilator Support?

Clinical Assessment• Increase Vt• Decrease trigger

effort• Optimize synchrony

– Patient - ventilator– Chest - abdomen

• Normoxemia• Normocapnia

Polysomnography• Improve sleep

architecture• Reverse thoraco-

abdominal paradox• Normocapnia• Normoxemia• Resolution of SDB

Summary

• NIV can be used for both acute and chronic respiratory failure– Goals for each are different

• The use of NIV is growing for both Acute and Chronic Respiratory Failure

• Pediatric indications require more data